Anaesthesia, 2010, 65, pages 82–93
. ....................................................................................................................................................................................................................
anaphylaxis management per the
Association of Anaesthetists of Great
Britain and Ireland guidelines [1]. Bron-
chospasm, the predominant clinical fea-
ture, was so severe it necessitated
disconnection of the breathing circuit
and manual compression of the chest
wall to facilitate exhalation.
Following a positive response to
treatment, a decision to proceed with
surgery was made together with the
neurosurgeons. Despite an increased
risk of coagulopathy associated with
anaphylaxis, the team felt that the need
to preserve hand function, which was
being compromised by the tumour,
justified the fact that we proceeded to
surgery. Surgery was uneventful. The
patient’s trachea was extubated success-
fully the following morning.
Tryptase and complement levels
were all normal; however, this doesn’t
rule out anaphylaxis [1]. Skin prick
testing for neuromuscular blockers
cefuroxime, propofol, lidocaine, remif-
entanil and latex were performed, all of
which were subsequently negative.
With hindsight, we suggest that move-
ment of the tracheal tube during
insertion of the throat pack precipitated
bronchospasm, and the high inflation
pressures with auto-PEEP resulted in
reduced venous return, hypotension
and cardiovascular collapse, thus
mimicking anaphylaxis.
We conducted an internal survey of
all anaesthetists in the Leeds General
Infirmary asking them about the timing
of administration of intravenous anti-
biotics in theatre and also to rank the
anaphylactic risk of various neuro-
muscular blockers. One hundred
responded (an 83% response rate).
Although 25% of respondents believed
antibiotics should be given more than
30 min before induction, only 15%
administer them before and 5% give
them with induction agents. Previously,
the Association of Anaesthetists of Great
Britain and Ireland has recommended
that antibiotic administration should be
separated from induction [2], thereby
allowing the normal haemodynamic
changes at induction of anaesthesia to
resolve, yet over 70% of respondents
administer antibiotics within 10 min of
induction.
 2009 The Association of Anaesthetists of Great Britain and Ireland
Anaphylaxis under anaesthesia is rare,
but in 60% of cases neuromuscular
blocking drugs are the causative agents
and in only 15% are antibiotics at fault [1].
Our assumption that cefuroxime rather
than vecuronium was the precipitant was
therefore likely to have been incorrect.
Suxamethonium is the most likely of the
neuromuscular blockers to cause ana-
phylaxis, followed by rocuronium [3].
Twenty-five percent of those surveyed
failed to rank suxamethonium as the
highest-risk agent and 40% thought
rocuronium to be low-risk. Whether
sugammadex will increase rocuronium’s
use waits to be seen, but clearly anaes-
thetists underrate its allergic potential.
Like the anaesthetists in the case above,
most respondents regarded vecuronium
as the safest neuromuscular blocking drug
(38%) or ranked it 5th or lower, out of 7
agents (65%). This is not in accordance
with the literature which gives vecuro-
nium medium risk [3]. Even though
cis-atracurium was regarded as the safest
agent by 27% it is only used by 2% of
respondents.
This incident highlights how the
deleterious effects of gas trapping during
bronchospasm can masquerade as
anaphylaxis. In addition, our survey
suggests that anaesthetists are poorly
informed regarding the anaphylactic
potential of neuromuscular blocking
drugs, and that the choice of the latter
is not guided by concerns over anaphy-
lactic risk. The administration of anti-
biotics, at induction, is at variance with
both ideal practice and guidance.
A. Kant
J. McKinlay
Leeds General Infirmary
Leeds UK
E-mail: justin.mckinlay@leedsth.nhs.uk
References
1 The Association of Anaesthetists of
Great Britain and Ireland. Guidelines –
Suspected Anaphylactic Reactions Associ-
ated with Anaesthesia. 2009. http://
aagbi.org/publications/guidelines/
docs/anaphylaxis_2009.pdf (accessed
11 ⁄ 10 ⁄ 09).
2 The Association of Anaesthetists of
Great Britain and Ireland. Guidelines –
Suspected Anaphylactic Reactions Associ-
Correspondence
ated with Anaesthesia. London, UK:
AAGBI, 2003.
3 Laxenaire MC, Mertes PM; Groupe
d’Etudes des Réactions Anaphylac-
toı̈des Peranesthésiques. Anaphylaxis
during anaesthesia. Results of a two-
year survey in France. British Journal of
Anaesthesia 2001; 87: 549–58.
Subcostal transversus
abdominis plane block
We would like to describe a case in
which we successfully used a subcostal
transversus abdominis plane block in a
frail elderly patient requiring a defunc-
tioning ileostomy. The patient had very
limited exercise tolerance and presented
on the emergency list. Following a CT
scan of the abdomen, a diagnosis of small
bowel obstruction was made, with a
stricture in the area of the ileocaecal
valve. The patient was warfarinised for
atrial fibrillation and had a pre-operative
INR of > 10. The surgeons wished to
perform a defunctioning ileostomy using
an incision in the right upper quadrant.
This patient was high-risk due to her
significantly limited physiological
reserve. After discussion, she declined
the option of postoperative admission to
the Intensive Care Unit (ICU). Tho-
racic epidural placement was unsuitable
due to the high INR. It was agreed
with the patient that the procedure
could be performed under local anaes-
thesia and sedation, and if this was
unsuccessful, she would be for conser-
vative management only. We consid-
ered using a transversus abdominis plane
block [1, 2] to provide analgesia; how-
ever, if conventionally performed, it
would only provide a reliable block for
incisions to the level of T8. Following a
literature search an alternative tech-
nique described by Hebbard [3, 4], the
subcostal transversus abdominis plane
block, used to provide effective analge-
sia for a cholecystectomy incision, was
chosen as a potential solution.
Following correction of her INR with
vitamin K and 1500 IU prothrombin
complex concentrate, we performed the
subcostal transversus abdominis plane
block following Hebbard’s description,
under ultrasound [5] (Fig 1). In contrast
91
Correspondence
. ....................................................................................................................................................................................................................
Figure 1 Needle and probe position for ultrasound guided subcostal transversus
abdominis plane block (Diagram kindly provided by Dr P Hebbard).
to the more familiar transversus abdo-
minis plane block the subcostal block is
performed at the costal margin with
hydro-dissection of the appropriate plane
caudally. We used 20 ml 0.5% levobup-
ivicaine and the block was confirmed
with loss of sensation to ice. A low-dose
remifentanil infusion (0.1 lg.kg.min)1)
was commenced to cover visceral stim-
ulation and the rate was gradually
reduced to 0.02 lg.kg.min)1 during
the procedure. The patient was comfort-
able throughout and we are confident the
block provided sufficient analgesia for
the large initial incision and dissection to
the small bowel. The patient made an
excellent recovery.
K. O’Connor
C. Renfrew
Ulster Hospital
Belfast, UK
E-mail: kieranoconnor@doctors.org.uk
References
1 Carney J, McDonnell JG, Ochana A,
Bhinder R, Laffey JG. The transversus
abdominis plane block provides effec-
tive postoperative analgesia in patients
undergoing total abdominal hysterec-
tomy. Anesthesia and Analgesia 2008;
107: 2056–60.
2 McDonnell JG, O’Donnell B, Curley
G, Heffernan A, Power C, Laffey JG.
The analgesic efficacy of transversus
92
Anaesthesia, 2010, 65, pages 82–93
ageing. The definitive treatment for
severe aortic stenosis is valve replace-
ment, which improves symptoms and
prognosis. Age itself is not a contrain-
dication to surgery; operative mortality
is low but is higher in patients with
comorbid conditions. Non-operative
treatment of aortic stenosis carries a
poor prognosis.
Despite the favourable results of
surgical aortic valve replacement, many
patients with severe, symptomatic aortic
stenosis are not offered surgery. The
Euro Heart Survey found that a deci-
sion not to operate was taken in 33% of
216 patients aged 75 years and over
with severe, symptomatic aortic stenosis
[2]. McBrien et al. did not report the
number of patients with aortic stenosis
who progressed to valve replacement
during the follow-up period, which
would be an interesting addition to
abdominis plane block after abdominal their study.
surgery: a prospective randomized The new evolving technique of
controlled trial. Anesthesia and Analgesia transcatheter aortic valve implantation
2007; 104: 193–7. provides an alternative, less invasive
3 Hebbard P, Fujiwara Y, Shibata Y, treatment for aortic stenosis, avoiding
Royse C. Ultrasound-guided transver- the need for median sternotomy and
sus abdominis plane (TAP) block. cardiopulmonary bypass [3]. The pro-
Anaesthesia and Intensive Care 2007; 35: cedure is safe and effective in the short-
616–7. term; long-term outcome data are
4 Tran TM, Ivanusic JJ, Hebbard P, emerging [4]. High-risk patients with
Barrington MJ. Determination of concomitant illnesses not suitable for
spread of injectate after ultrasound- surgical aortic valve replacement may
guided transversus abdominis plane now be offered transcatheter aortic
block: a cadaveric study. British Journal valve implantation. Therefore, as the
of Anaesthesia 2009; 102: techniques and indications for less
123–7. invasive treatment of aortic stenosis
5 Hebbard P. http://usra.ca/UIA/ continue to evolve, the timely diagnosis
Getfile.php/id=30 (accessed of the disease will become even more
important.
09 ⁄ 09 ⁄ 09).
McBrien et al. rightly call for ade-
quately resourced echocardiography
Peri-operative echocardio- services so that pre-operative echo-
graphic diagnosis of aortic cardiography in hip fracture patients
stenosis with suspected aortic stenosis does not
delay operative fracture fixation. Delay-
McBrien et al. [1] recently analysed the ing surgery beyond 48 h after admission
management and outcome of 272 with hip fracture may increase 30-day
patients identified with previously and 1 year all-cause mortality [5]. We
undiagnosed aortic stenosis before hip suggest that valvular intervention in hip
fracture surgery. We congratulate the fracture patients with severe aortic
authors on reporting this large series of stenosis should not delay surgery and is
patients with aortic stenosis undergoing optimally performed after hip fracture
noncardiac surgery. fixation.
Degenerative aortic valve disease is We support McBrien et al. and rec-
common and closely correlated with ommend early identification of aortic
 2009 The Association of Anaesthetists of Great Britain and Ireland